A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

Position the client prone and have the respiratory therapist perform postural drainage.

Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

Increase oxygen to 70%.

Switch oxygen to a nonrebreather mask.

Answer and Explanation

The Correct Answer is B

A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.

B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).

C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.

D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Change the dressing when it is saturated:

This intervention is the most appropriate for managing a deep wound with a wet to-damp dressing. Wet to-damp dressings are designed to maintain a moist environment conducive to wound healing. Changing the dressing when it becomes saturated with wound exudate helps prevent excessive moisture accumulation, which can lead to skin maceration and potential infection. It ensures that the wound bed remains in an optimal healing environment and reduces the risk of complications.

B. Assess the wound bed once a day:

Assessing the wound bed is an essential part of wound care, as it allows the nurse to monitor healing progress, assess for signs of infection, and evaluate the effectiveness of the chosen dressing. However, the frequency of wound bed assessment may vary depending on the specific patient's needs and the type of dressing being used. While daily assessment is generally recommended, it does not directly dictate the timing of dressing changes for wet to-damp dressings, which are primarily changed based on saturation levels.

C. Contact the provider when the dressing leaks:

Contacting the provider when the dressing leaks or when there are concerns or complications is an important step in patient care. Leaking dressings can indicate issues with the dressing application, excessive wound exudate, or potential complications such as infection. It's crucial to inform the provider promptly so that appropriate interventions can be implemented, but this instruction is more reactive and does not specifically address the timing of dressing changes.

D. Change the dressing every 6 hours:

Changing the dressing every 6 hours is not typically recommended for wet to-damp dressings unless specifically indicated based on the patient's condition and the amount of wound exudate. Frequent dressing changes can disrupt the healing process, cause unnecessary trauma to the wound bed, and increase the risk of infection. Dressing change frequency should be based on the assessment of wound exudate and the dressing's ability to maintain a moist environment.

A. Prevents complications, such as meningitis or pneumonitis B. Decreases the probability of recurrent outbreaks C. Shortens the outbreak and lessens the severity of symptoms D. Eliminates the likelihood of spreading the infection to others

Correct Answer is C

Explanation

A. Prevents complications, such as meningitis or pneumonitis

While oral acyclovir can be effective in managing HSV infections and reducing the severity of symptoms, it is not primarily used to prevent complications such as meningitis or pneumonitis. These complications may occur in severe cases of HSV infections, but oral acyclovir's main goal is to manage outbreaks and reduce symptoms.

B. Decreases the probability of recurrent outbreaks

Oral acyclovir can help reduce the frequency of recurrent outbreaks in individuals with HSV infections. However, it does not completely eliminate the probability of recurrent outbreaks. Some individuals may still experience occasional outbreaks even with regular use of oral acyclovir. The medication is more focused on managing outbreaks when they occur rather than preventing them entirely.

C. Shortens the outbreak and lessens the severity of symptoms

This option is the correct choice. Oral acyclovir is effective in shortening the duration of HSV outbreaks and reducing the severity of symptoms such as pain, itching, and lesions. It works by inhibiting the replication of the virus, which helps in faster healing and symptom relief. However, it does not cure the infection or eliminate the virus from the body.

D. Eliminates the likelihood of spreading the infection to others

While oral acyclovir can help manage outbreaks and reduce viral shedding, it does not completely eliminate the risk of spreading the infection to others. It can reduce the likelihood of transmission during active outbreaks, but individuals with HSV can still shed the virus and be contagious even when they are not experiencing visible symptoms. Therefore, other precautions such as practicing safe sex and avoiding close contact during outbreaks are also important for preventing transmission.

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Naxlex Comprehensive Predictor Exams

A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

Correct Answer is A

Explanation

A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

Correct Answer is C

Explanation

A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

What is the common factor for etiology and pathophysiology of folliculitis, furuncles, and carbuncles?

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